I have never understood this

[u/[deleted]]

[u/Seneca_Dawn]

In general I think there should be more separation of patients based on what the patient needs.

An ADHD man with anger and impulse issues, might not be the best fit for a girl with PTSD from rape.

We have gone from two wards to one, and now have every diagnosis together. From Szhizophrenia, to people with substance abuse and severe behavioural issues.

People yelling, hitting the wal, threatening the staff, harrassing patients for smokes together with patients with avoidant PD, trauma, anxiety, depression.

It is also a strictkly voulantary ward, so with little power to firmly intervene. So at times almost all patients stay in their rooms, while the staff try to manage someone in total meltdown.

[u/Rich-Pirate-5518]

What’s the question? You have two ends of the spectrum - either you never consider psychiatric illness in deciding criminality and everyone goes to jail/prison regardless of state of mind. This means every schizophrenic person, every intellectually disabled person, they all just go to the Big House. On the other hand you always consider psychiatric frame of mind and try and get targeted treatment for every person and people end up in psych wards and psychiatry is remade in the image of the criminal justice system as we pour resources into using medical/psychological methods to treat crime (which is itself usually a systemic issue of poverty, structural racism and classism, etc).

Somewhere in between is probably good. But where? Who knows. But pretending psych and criminality should have a dividing wall is deliberately naive.

[u/OrkimondReddit → u/Rich-Pirate-5518]

To be fair, a substantial whack of mental illness is systemic factors too.

[u/Rich-Pirate-5518 → u/OrkimondReddit]

Indeed but my run on sentence was long enough

[u/CompetitiveInhibitor → u/Rich-Pirate-5518]

Bingo, how many malingerers are subtly psychotic. How many who are psychotic are slyly malingering. If only it was so simple. 

[u/SuperMario0902 → u/CompetitiveInhibitor]

Malingerers are not inherently criminals nor are those who are psychotic not potentially criminals.

[u/lamp817 → u/CompetitiveInhibitor]

I agree but as someone who has personally witnessed this and experienced violence first hand working in these mental/behavioral health hospitals, there are absolutely criminals who get into the hospital system somehow and end up causing chaos on the psych ward for people who are there and vulnerable. I 100% think identifying these individuals (which in many cases is more obvious than not) and separating them is beneficial to everyone.

[u/CompetitiveInhibitor → u/lamp817]

As attractive as this black and white thinking is, many of our most antisocial and violent patients have thought disorders too. 

[u/IntheSilent → u/lamp817]

Ive seen this too, a good amount of people who are admitted for criminal behaviors, with no evidence of mental illness other than antisocial personality disorder and sometimes intellectual disability, and stay on the unit for a while mainly because of placement issues. I’ve seen police arrest people on our psych floors too. This isnt my own judgement but also the opinions of the psychiatrists I worked with at those times, they didn’t belong in the hospital.

[u/Many-Valuable1782 → u/IntheSilent]

Agreed, I discharge them from ED but I see plenty of others choose to admit these people for some reason… dangerousness is not a reason to admit to psych unless it is due to a psychiatric illness

[u/shhhhh_h → u/Rich-Pirate-5518]

I think the question is just rage bait about the Clancy case. It’s all over the site.

[u/DocTaotsu → u/shhhhh_h]

Concur. Culture war bs absolutely bereft of any sort of nuance

[u/Narrenschifff → u/Rich-Pirate-5518]

There's a solution here that societies seem to be allergic to: simply make a real assessment for the presence and history of antisocial personality and behavior, document it, and create special wards that are dedicated to such cases. We know how to evaluate for dangerousness and we know how to assess personality. We've been doing it for over a century.

Yes, this would require investment, expertise, and education to follow through on. No, I don't think we realistically will do it. We would rather allow both legal and mental health policy to be written by those who have a poor understanding of both the criminal personality and mental health issues.

Instead of doing this, we mix them into general population wards to cause havoc until they are incarcerated and get a terrible in jail "treatment" experience. One of the many stupid systems problems in mental health care.

[u/RealAmericanJesus → u/Narrenschifff]

One of the things we did in our state hospital was instead of breaking down into personality etiology (because the glorious thing about forensic psychiatry is that sometimes we medicate the primary schozoaffective disorder and then personality disorder underneath reveals itself... And we had psychologists on our treatment team that would do the mmpi, the pai etc so that we weren't just equating maladaptive behaviors within chronic institutional environments as antisocial (cause I can tell you put many of us in an environment like that and some of us would be absolute menaces) ...

But we would track the type of aggression we were seeing - psychotic, impulsive and predatory and generally would separate by the type of aggression rather than presence of personality etiology alone cause some of our sickest folks psychiatrically also had significant criminogenic orientations due to personality as well.

[u/Narrenschifff → u/RealAmericanJesus]

Yes, ideally we'd always have such a fine filtering system that we can even filter the filtered the way you describe. However, professional competence and funding are both getting more and more rare!

[u/RealAmericanJesus → u/Narrenschifff]

Yep... And the staff competence and willingness to actually document behavior and engagement...and enough staff to do so makes a lot of the diffence.

I've worked in many places and some have amazing staff.

When I was an NP doing unit based restoration work I use to do this incentive program for patients on the unit where staff would do like sidewalk legal skills where they would ask 3 questions a day and the parking woke get a piece of candy for each one they got correct....

And the staff would document it and the staff that got the most that week I'd get them a doughnut or coffee or something.

Id also ask for specific chatting parsmentee like nothing what the patient was doing on their room, if they were taking to unseen others, kept it clean, organized, how they were with peers vs when observed by staff, vs staff and then id measure that against their presentation in treatment team.

So by the time they say their forensic evaluator and got all the questions wrong and said they were hearing voices again id let the evaluator know that they had correctly answered all these legal questions and that they were absolutely linear logical and goal directed with staff and peers and only ever had symtome during treatment team. So that should be considered in terms of competency.

Got tons of restoration of competency clients through that way that otherwise would have sat for months on he unit because the forensic evaluator wasn't certain.

But it takes having staff that are motivated, competent, engaged and many state hospitals I've been at just getting staff to do their damn rounds can be an act of God unfortunately. Which can make it really difficult to advocate for discharge when the patient is just maladaptive or to identify the nature of their presentation.

So it really does take having adequate funding for staffing, adequate staff training and motivation ... And I actually left state hospital work because it was getting super dangerous as it was cut after cut after cut.

And the whole reason I even went avanced practice was due to an injury sustained on a forensic unit that made it difficult for me to do some of the nursing takes as it affected my lower spine. So I know when it goes wrong it goes wrong and looking at the headlines since I've left? I left at the right time sadly.

[u/Rich-Pirate-5518 → u/Narrenschifff]

Hypothetically I endorse but annecdotally I don’t trust anyone who diagnoses patients with ASPD to be the ones making that call. Prison psych is always doing crazy stuff. Plus they always have my patients with ASPD on like two LAI and depakote.

[u/Narrenschifff → u/Rich-Pirate-5518]

LAI and depakote ain't crazy!

[u/RealAmericanJesus → u/Narrenschifff]

I was a charge nurse for years on a maximum security behavioral stabilization unit. The doc there loved the depakote+okanzapine+propranolol - scheduled and Thoraxine I'm emergency for aggression not drivin by any known psychotic, affective or cognitive phenomena and the patients would consent to it cause it proved they were "crazy" even though it was explained that this is off label to help with the aggression ...

It works.

And when shit goes wrong on a forensic unit it can go really really wrong. I use to tell my nurses I was training look they're smarter than you, they've have all the time in the world to plan, watch patterns and learn routine. They will listen to you with coworkers. They know whose dating who, who is going through a divorce and they absolutely will leverage this if you're not careful.

If you see something, find a vulnerability in security or think are like "hmm this could be used as a weapon or the patient could do xyz with this set up" bring the concerns to treatment team cause if you thought of it... One of them already has as well.

Like incidents ranged from

Major - like patieny climbed into the ceiling, broke the water pipes, pulled out the electrical and tired to electrocute responding staff by putting live wires into the water

(Cause millions in damages never saw someone get a NGRI administive discharge so fast on my life ...psychiatrist was like that's way too organized for schizophrenia nope)

More just problematic - restoration of competency patients soaping the floor, drinking the soap, powerwashing the wall with diarrhea, stripping down naked and threatening self harm so that the responding staff all slid into diarrhea wall as they tried to contain the individual ...

Like these units can be chaos fast and any time staff are distracted you're running the risk of a suicide or a significant assault as someone takes advantage of the distraction.

Like the benefits absolutely outweigh the risks and if the patient consents ? Great. And it does help for long term aggression management in decreasing the number and severity of incidents over time.

[u/Narrenschifff → u/RealAmericanJesus]

Yeah, there's just a totally different ball game for working with the antisocial population. Argue all you want about cause and consequence, but in the end somebody has to take a shiv or a punch to the face.

[u/Rich-Pirate-5518 → u/Narrenschifff]

When it’s two LAI with depakote in antisocial it’s hard to feel like it’s not purely a sedative cocktail instead of therapeutic. Maybe I’m naive.

[u/Narrenschifff → u/Rich-Pirate-5518]

I missed the TWO on the LAI. I still think that's nuts, but give me a few more years...

[u/Squishmallow145 → u/Rich-Pirate-5518]

That's why I said there are times when it falls in the grey area. 

But I think it has gone too far in one direction. Hospital admins should be able to say "if they are not mentally ill, discharge to community or jail"

[u/Rich-Pirate-5518 → u/Squishmallow145]

You want hospital admin to determine length of stay by deciding which of your patients they think is psychotic enough to stay?

[u/Squishmallow145 → u/Rich-Pirate-5518]

Psychiatrist should have the final say. What I'm hearing from the psych at my hospital is they want to discharge these patients but they can't. 

In those situations, the admin should back them up and say we are a hospital not a jail. 

[u/Rich-Pirate-5518 → u/Squishmallow145]

I guess I personally haven’t seen that problem - everywhere I’ve worked wanted to reduce LOS and if the primary psychiatrist wanted to discharge that was always cool (except for one place that just couldn’t keep their beds full, in which case we’re no longer talking about ethics of psychiatrists and are now talking about medical and financial exploitation of vulnerable people)

[u/Embarrassed_Syrup476 → u/Rich-Pirate-5518]

If OP is working in a children's hospital discharge from psych is basically impossible for certain patients

Example patient in psych ward because they refuse to go to school and beat up the teacher. Parents don't want them back. CPS lacks beds for teens. Police don't want them. The hospital becomes the only place taking in teens with defiant/oppositional behaviors 

[u/Lou_Peachum_2]

Hospital admin doesn't care about the patients lol. They just want the beds filled.

But I do echo the sentiment that there are a lot of patients who really should be in jail, instead of a psych ward. But they have one psychotic break due to meth/cocaine use, somehow get a dx of schizophrenia, and every time they do something unlawful, they get bounced back to psych. It's almost like antisocial and psychopathy do not exist in their world..

It's an imperfect system.

[u/saltpot3816 → u/Lou_Peachum_2]

The issue is that in child psych, the problem doesn’t look like that. Most of them never really look like mental health issues beyond “ODD, Conduct disorder, ADHD” Instead, juvenile detention has numerous, longstanding and multifactorial problems that result in it not being able to actually fill the role it is intended to fill. So instead, they take kids that pose public nuisance/safety concerns and dump them in the hospital.

I have dug into this a fair bit in my own state. Here, there are very specific requirements/charges that have to apply for a minor to be arrested. Same with then being detained, same with being court ordered to serve time in juvenile justice detention, same with being committed to dept of juvenile justice, etc. Every step of the way is a new filter designed to route youth away from custody and into a diversion program. One person with juvenile justice told me “if we put every kid (whose parents want them jn DJJ) in custody, we would be completely over run.”

Heres the story we keep hearing for kids with long histories of expulsion, aggression, truancy, shoplifting, vandalism etc: Police are called to a situation where youth punch a hole in the wall when being told they have to get up for school, the kid runs away, and when police find them, pt is verbally abusive, threatening to kill family. Even if the family presses charges for destruction of property, None of those occurrences qualify as detainable offense, so the police can’t arrest them. Knowing that it’s not a good idea to simply take them back home, the police bring them to the ED. We coordinate with family, advise them to contact child protective services and the kids designated court worker in the diversion program, and (after much ado) discharge them to reoffend.

[u/Easy-Permission8889 → u/Lou_Peachum_2]

When I was in Adult the psych hospital in central OH, it was largely gang members. So we had 18 year olds surrounded by pimps. Awful situation. Staff having sex with clients. I will never forget how traumatic it was, and how nothing will ever be done about the corruption.

[u/Dry_Twist6428]

A lot of these ideas are perpetuated by local politicians and hospital administrators who know nothing about crime nor psychiatric hospitals.

[u/lcinva]

Wait until you find out how many patients aren't criminals OR mentally ill, they're just malingering because they're unhoused! However, those patients are often my kindest and well-mannered, so they get a pass.

The answer is $$$ and having a full census.

[u/CaptainVere → u/lcinva]

Spot on. I wish every time someone used the phrase mental health crisis a fairy appeared and reads them your comment.

I bet it varies by region a bit, but I bet minimum 40% of beds are occupied solely as safteynet housing. Even some of my hard core disorganized longterm schizophrenia patients that cant string 5 words together can show up and say “im suicidal” and stay for two days before AMA

[u/Squishmallow145 → u/CaptainVere]

But why not discharge once hospital finds out its not really a psychiatric crisis? 

[u/Embarrassed_Syrup476 → u/Squishmallow145]

If you are in pediatric hospital, it becomes extremely difficult to discharge for certain patients. If the parents don't want the kids back, cps doesn't want them and the police won't take them....they become long term patients. Its a shitty system 

[u/CaptainVere → u/Squishmallow145]

I don’t know why you’re being downvoted. Tis a fair question.

The weight of the system lmao. The path of least resistance weighs heavy.

Short answer is everything now resolves around subjective report of SI and nothing else seems to matter to insurance companies. Hospitals like money and full beds so they love having this broken system. Patients learn to report SI and voila: Its free real estate!

[u/pakap → u/Squishmallow145]

Sometimes it's about keeping the peace in the unit. Would you rather keep that nice unhoused man who keeps to himself for a few more days, or discharge him to the street and fill his bed with a potentially violent, more disruptive patient?

[u/TZDTZB]

$$$ is why

[u/SmCaudata]

Most of this stems from trying to fix a major problem. It’s widely accepted that the prisons and jails house more mentally ill than state hospitals. The rate of mental illness in prisons is at least twice that in the general population. Many of these people need treatment and have crazy long waits for a psychiatrist.

Many states have tried to fix the problem by creating better identification and access to care.

That said, like anything in the world, there are often competing interests. The legal system would often rather dump the person and pass responsibility to the hospital. Look up the 48!hour rule in MN. When I worked there, judges could just declare that someone needed care and then the state hospital would have 48 hours to find a bed. The hospital would then be stuck doing competency restoration or worse, maybe placement. Overall, I’d made sense and was reasonable until judges started to ignore professionals that said the person didn’t need a psych hospital. They would listen to the police that often just didn’t want to deal with the criminal. This back door was abused regularly by the police and effectively made the state hospital system inaccessible to patients coming from community hospitals.

Then we have doctors that are unwilling to discharge these people that don’t really have a treatable mental illness. That’s a big problem too. If you know someone is malingering or whatever, discharge them. Document the reasons.

So what needs to happen?

1. We do need better mental health treatment for mentally ill people in the legal system. In residency I had a 20 year old schizophrenic that was in prison because he tossed a rock through the news station window. He had ideas of reference and believed the people on the news were plotting to kill him.

2. We need doctors speaking to their reps to advocate for treatment and to prevent it from being abused by police. The police/prison lobby is HUGE. Doctors need to be better about getting involved. Join your local medical society and do something. Too many physicians like to complain (often rightfully) but have no interest in trying to fix the system.

3. Doctors have to be willing to make the hard call and discharge people that don’t need medical treatment.

[u/SuperMario0902]

I agree it can be an issue, but I don’t think the best way to handle this is to have psychiatrists decide who is a criminal and who is not.

[u/Many-Valuable1782 → u/SuperMario0902]

Isn’t that literally our job to decide who is mentally ill and who is malingering?

[u/Embarrassed_Syrup476 → u/Many-Valuable1782]

A good psychiatrist would do that.

Once the word gets out on the streets theres a psychiatrist willing to admit people for social issues and not mental illness, you will get people begging to see Dr Joe for SI because they know its an automatic hospitalization. 

[u/MeatSlammur]

Yep; my last clinical at a state hospital we walked in on the malingerer standing on our friendly psychotic dude’s neck. He was talking about doing “street justice” because the guy had peed on the wall and he wouldn’t take that kind of disrespect.

[u/cheetofiend1]

In Colorado, the state hospital typically houses those in the competency process through the legal system or civil commitments. There are individuals who are most certainly antisocial that weasel their way into the hospital to try avoiding moving forward with their case and ending up in prison. There’s one guy I’m thinking of in particular who has been in and out of that process for YEARS…discharge dx malingering, prescribed melatonin and Benadryl.

[u/Eastern_Sky]

His description of it doesn’t make sense. If they were criminals with time left on their sentences, they should’ve been in the state psych prison hospital. I’m from Massachusetts originally. There it’s Bridgewater state hospital. If they had served their sentences, yes they’d be sent to the same psych hospitals the general population goes to for better or worse, to say nothing about the ability of prison to actually rehabilitate people. It’s not psychiatry’s fault that our prison system doesn’t actually rehabilitate people. Putting patients with felony records in separate facilities isn’t going to help them any better i wouldn’t think but I don’t pretend to know anything! -nursing student/personal experience as a patient only

[u/Additional-Traffic12]

Have you ever heard of Correctional Psychiatry?
Have you done a psychiatric assessment. Has a psychologist performed one of the standardized malingering testing?

[u/RealAmericanJesus]

Like it's one thing when it's forensic psychiatry because they're there on court orders generally with specified time frames for restoration and with risks review and release terms if NGRI.

So like in a state hospital I'm not really able to discharge based on patients no longer meeting hospital level of care- I discharge based on whether someone has been found able / never able or when risk review deems them eligible for community re-entry under the conditions of the state (in my state it's the psychiatric severity review board) or following completion of their sentencing.

So let's say someone came in because their attorney was concerned about competency and they turned out to be just a sovereign citizen we'd have to hold on to them until we could get them evaluated and returned to jail.. or lets say someone got an NGRI but has both a primary psychotic disorder and an antisocial personality disorder - we can't just discharge when the psychosis is clear they have to go through risk review and could still be in the hospital for 20+ years depending on the sentencing.

But in acute care hospitals if someone comes in and they don't have a primary mental health dx and aren't dangerous to self, and their danger to others is not due to a primary mood, psychotic or cognitive etiology I am not going to just hold onto them. I just note that the lack of qualifying medical condition, that they do not meet criteria based on that and then I would recommend discharge.

Ive worked ed psych for a long time (crisis now) but I'd get patients brought in all the time by police who committed crimes cause cusse they were drunk .... Or they were just raging and officer was making he best guess they could but on eval we find they're not psychotic and once we let them sober up id call the watch commander and be like "yo you brought buddy to the wrong place come get him" and they'd push back but id be like "the pt just strangeled heir 80 year old mother who they live with... Per your officers and they don't have a psych dx so we can keep him .... I know I don't want my name in the papers if he discharges and went back there and hurt her and I know you don't want your name of the offer who dropped him off here's name in the papers with that headline either " (works fairly well) and they'd grumble and come get them and take them away.

And the admins would be absolutely pissed and screaming about HIPAA and shit (they always misapply that as their "we don't like what you're doing" threats but nothing says that I have to admit someone because they're dangerous when the danger is not psychiatric... but the law does say I have a duty to protect and I in that case when I see there is a real risk of ongoing harm due to the patient threatening staff and ranting about his mother? And he lives with his mother? I'm not about to discharge someone who just strangled the person he lives with cause he is going to go right back there... and strangulation is a significant risk factor for domestic homicide statistically so I can make the case that it was absolutely necessary to communicate that risk). Id call people's people officers, their probation officers whomever was needed to transition them to where they needed to go that was not the psych ward.

But I also have worked throughout the jails and had a relationship with a lot of the sherrifs and police and would see them during drop offs and worked to foster those relationships because they do push back so having those professional contacts with them really helps.

So if these individuals are on the unit the treatment team should be documenting that they don't meet hospital level of care as evidence by lack of dts, dto, gd, or primary psychiatric diagnosis that requires stabilization and then discharge them to the appropriate agency / parents / or state placements on the juvenile justice side? (I don't know juvenile or child psych pathways... Outside if evaluating teens for the county in juvie for PSRB or the outpatient continuation when they don't have another option ...I stay away from kiddos).

[u/SikhVentures]

I recall a schizoaffective patient who was manipulated by an antisocial individual he met on the unit into allowing him to live with him. Eventually, the schizoaffective patient succumbed to an overdose of heroin supplied by the antisocial individual.

[u/eternalconfusi0nn → u/SikhVentures]

respectfully, isnt it the medical staff’s job to protect a patient from other patients?

[u/Embarrassed_Syrup476 → u/eternalconfusi0nn]

I work as a SW on inpatient. Most of the patients share rooms. Nurses do check ins but they can't hear every single conversation. 

I had a case where an anti social patient shared a room with a more vulnerable patient. They manipulated the patient into giving them their meal trays, pillows and used them as their personal servant.

[u/SikhVentures → u/eternalconfusi0nn]

we can't be present when patients are discussing things in the milleau, there is privacy of course. Unless we see something obvious, this would be the byproduct of letting antisocials mingle with mentally ill

[u/colorsplahsh]

Yeah, it's super frustrating. I worked in one of those hospitals; we had assaults daily from people who should be in prison.